Advice for acute medical staff when managing a patient admitted with a severe eating disorder

1. I have a very serious eating disorder and I can often look more well than I actually am
2. Because of the strength of my eating disorder thoughts, I may not be making very good decisions about my care, even though I may appear coherent and knowledgeable
3. I may not be aware of my own difficulties and disability, for example I may say I will go home and eat, or not make myself sick, but in reality, I may not be able to control this
4. For this reason, I may not have capacity to make decisions about my care.  Although I may appear to understand a particular decision and can highlight the advantages and disadvantages of the decision, due to my eating disorder thinking, I may not be able to weigh up this information necessary to make a decision.  It may be better to get someone experienced in eating disorders to come and talk to me.
5. I will likely need water and food.  I may refuse these because I am struggling with my thoughts, not because I want to die.  Please understand this and try to talk to me about it.  Please don’t tell me off, or just ask me to eat.  It is unlikely to work.
6. I may need to be assessed under the Mental Health Act if I am struggling to comply with the treatment designed to help me get better.
7. Please do not discharge me if there are any signs of physical risks, unless someone who is experienced in eating disorders has assessed me.
8. Please contact my community eating disorder service to find out more about me.  If I have come to hospital at night time, it may be best to wait until the next day.
9. Please look at the Medical Emergencies in Eating Disorders guidance (MEED) which describes the best way to treat me.
10. Please do not discharge me based only on the correction of low potassium or low glucose without careful consideration. I may be at increased risk if you send me home.
11. I may need transfer to a specialist eating disorder unit (SEDU) if I am really unwell.
12. Please ask Liaison Psychiatry team to come and see me, as they may be able to help with decision making.
13. Please look after me as I am likely to be very frightened

TRANSFER TO EDU WHEN MEDICALLY STABLE

The following guidance can be used for the first 24-48 hours of admission to an Acute Medical Ward

1. SENIOR REVIEW BY GASTROENTEROLOGIST
2. Obtain as accurate a weight and height as possible.  Repeat weight at the same time each day (ideally first thing in morning).  Be suspicious of falsification of weight.
3. Bloods daily to include:
   • FBC, U&E, LFT, Phosphate, Magnesium. Bicarbonate, CK, Calcium, Random Glucose, Clotting Screen
   • Watch out for refeeding syndrome
4. ECG daily (looking for severe bradycardia and QT prolongation).
5. Attempt to re-feed cautiously at no more than 20 calories per kg per day (please see MEED Guidance or Appendix 2 for more information).
6. Re-hydrate if appropriate 1-2 litres per day, cautiously, either orally, s/c or i/v.
7. Prescribe:
   • FORCEVAL (one tablet daily)
   • THIAMINE (100mg bd)
   • VITAMIN B CO STRONG (2 tablets tds)
   • CALCICHEW D3 FORTE (2 tablets od).
8. Avoid diuretics if oedematous.
9. Avoid laxatives.
10. If any signs of hypophosphatemia, supplement phosphate either orally (4 to 6 tablets daily) or intravenously (if phosphate <0.5).
11. If any signs of hypokalaemia, supplement potassium either orally (Sando-K 2 tablets od to 2 tablets tds per day depending on severity) or intravenously (if potassium <2.5).
12. Encourage bed-rest.  Attempt to contain patient on the ward.
13. If patient requests discharge, arrange a senior review, ideally through an eating disorder specialist or Liaison Psychiatry, a capacity assessment and/or detention under Section 5(2) of the Mental Health Act.  A Mental Health Act assessment will then be arranged within 72 hours.

1. Referral for dietetic assessment received.
2. Obtain accurate weight.
   • This should be done on initial admission to ward.  Patient should be weighed wearing only hospital gown.  Weight should be repeated the next morning prior to any oral intake (diet or fluids) and after bladder emptying to exclude the possibility of fluid loading.
3. Obtain accurate height.  Calculate Body Mass Index (BMI).
4. Calculate nutritional requirements.  Initiate feeding at 20Kcal/kg.  If patient is at high risk of    refeeding syndrome, consider commencing feed at 10Kcal/kg.
   • Criteria for high risk patients include:       
     • BMI <13kg/m²
     • *Low sodium <125mmol/l (may suggest water loading)
     • *Low potassium <3mmol/l (may suggest vomiting or laxative abuse)
     • Hypoglycaemia
     • Raised Transaminases
   • *Low potassium and sodium may also be caused by malnutrition with/without water loading/vomiting/purging.
5. If lower rates of feeding are used, regular review is essential to increase regimen as soon as clinical condition allows (Check MEED Guidance)​​​​​​​
   • Supplement diet with:​​​​​​​
     • FORCEVAL / SANATOGEN A-Z (1 tablet daily)
     • THIAMINE (100mg bd)
     • VITAMIN B CO STRONG (2 tablets tds)​​​​​​​
     • CALCICHEW D3 FORTE (2 tablets per day)​​​​​​​
6. Establish plan for initiate of nutrition support.
   • ​​​​​​​​​​​​​​Oral feeding with food is the preferred method of refeeding.​​​​​​​
   • If the patient refuses to eat food, then consider use of nutritional supplements.
   • If both food and fluid are refused, nasogastric (NG) feeding may be indicated. 
   • If NG feeding is to be used, then meal plans or supplement drinks should be avoided at this stage to avoid increased refeeding risk.
   • Use of a bolus NG regime rather than continuous feeding should be considered to facilitate monitoring.

​​​​​​​​​​​​​It is essential that all patients with eating disorders have strict food and fluid charts in place.

Examples of refeeding regimens for tube feeding, oral nutritional supplements and addition of solid food may be seen overleaf.

Table 1: Example for refeeding a 35kg patient using tube feeding

Source: British Dietetic Association (2011)

Table 2: Example for refeeding a 35kg patient using oral nutritional supplements

Source: British Dietetic Association (2011)

Table 3: Example for refeeding a 35kg patient using food

Source: British Dietetic Association (2011)